L e a d e r s h i p , r e s o u r c i n g a n d g o v e r n a n c e convincingly used to explain how different nations have ended up with disparate health care systems or whether they have introduced national health insurance. Australia, as a federation of states and territories, has more dispersed and contested authority than the unitary national system of the Netherlands. It also has a Westminster parliamentary system with two dominant parties, which is quite different to the multi-party coalition governments of the Netherlands, which must work together in order to achieve their objectives. This difference is important in each state’s version of national health insurance and related reforms. In addition, a classification of welfare state types (Esping-Anderson, 1990) is useful for highlighting the difference between Australia (a ‘liberal’ welfare state, with means-tested assistance and modest transfers to low-income citizens) and the Netherlands (a corporatist welfare state, where the granting of social rights was hardly ever a contested issue). Based on this, the health care system in the Netherlands could be expected to have a greater emphasis on social solidarity. With regard to national health insurance, the Netherlands has had large friendly societies operating since the late 19th century on a voluntary basis, and mandatory insurance for lower income earners since 1941. The system in the Netherlands has its origins in World War II, well in advance of the idea that the welfare state was facing a fiscal crisis. The failure to establish a national health service (NHS) in Australia along the lines of the British service in the post-war period meant that the universal scheme finally introduced in 1983 was established in the face of growing concern about public budgets (Lewis, 2014). In 2005, with little political debate or public opposition, a new form of health insurance was introduced in the Netherlands. All residents now have to take out basic health insurance with an insurer of their choice and insurers have to accept any applicant. These changes were market inspired, but the country has not moved away from its social solidarity principle, with tight regulation, oversight of competition and safeguards for care standards continuing to ensure equity (Jakubowski et al., 2013). This reform also illustrates that in the Netherlands, while changes in political coalitions occur, these do not appear to have much impact on the overall direction of reform. An analysis of Dutch health care reforms in the period 1987–2007 by Okma and de Roo (2009) concluded that, although the governing coalition changed seven times over this period, incoming coalitions either carried on with implementing their predecessors’ plans, or at least rarely undid the reforms already undertaken. In contrast, the Australian system lends itself to policy reversals. The initial universal health insurance scheme, Medibank, had barely been introduced when the Labour government was dismissed in 1975, and it was effectively abolished by the new conservative government. Just as the population had returned to voluntary health insurance, another Labour government was elected in 1983 and Medicare – the new universal health insurance scheme – was introduced. Reforms aligned with changes in national government have continued in Australia, although these have more recently been smaller moves. Here we can see two different types of incrementalism in action – a series of adjustments that result in substantial change in one direction (Dutch), compared to a series of adjustments in different directions that amount to reversals (Australian). In addition, while the impetus for reforming health systems in both cases has been cost containment and the idea that greater private sector involvement and competition is needed, change in the Dutch case continues to reflect the solidarity principle, regardless of the government in power. The Australian approach remains both more individualistic and more likely to include policy reversals. Politics There is no better focal point for examining the political dimension of governance change in health than the relationship between the state and the medical profession. In the health sector, policymaking is shaped by the self-governing capacity of the medical profession, which in turn is related to how state institutions such as health insurance are structured. One important consideration is whether the corporate structure of the professions is more internal or external to the state. In Australia the medical profession has functioned as an external pressure group, as in other Anglo nations, with powerful professional bodies. In many European countries the profession has been much more integrated with the state. In the Netherlands there is a long history of a limited number of associations being granted the legitimacy necessary to be able to pursue their collective self-interests through negotiations with the state (corporatism). In Australia, professions have largely developed externally to the state and then functioned as pressure groups, rather than being internal to the state apparatus. Over the last four decades, many health policy reforms that have sought to restrict or stop the growth in expenditure on publicly funded services have presented direct or indirect challenges to the ideal of professional control and autonomy by recasting the work of professionals. Some have argued that the medicine–state alliance is being displaced by managers as the custodians of cost Figure 1 Governance change in the health sector Dimension Australia The Netherlands Institutions Multiple changes in different directions Multiple changes in same direction (national health insurance) Individualism Solidarity Politics Little change in professional authority Some reduction in professional authority (state–profession relationship) External to state Internal to state Ideation Small attempts to shift to social determinants Little discussion of social determinants (foundational model of health) Biomedical Biomedical 112 Commonwealth Health Partnerships 2015
Commonwealth Health Partnerships 2015
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